Primary or secondary, with symptoms and size deciding treatment
Expansion
Classification
- Primary spontaneous - no underlying lung disease. Typically tall, thin, young smokers
- Secondary spontaneous - underlying disease, usually COPD. Far worse tolerated, so the threshold for intervention is lower
- Traumatic and iatrogenic - after central line insertion, pleural procedures or positive pressure ventilation
Tension pneumothorax is a separate emergency: trachea deviated away, absent breath sounds, hyperresonance, distended neck veins, hypotension and severe distress. Treat immediately with a large bore cannula in the second intercostal space mid-clavicular line, or the fourth or fifth space in the anterior axillary line, then a chest drain.
Management principle: symptoms and physiology matter more than the measured size, and a secondary pneumothorax is treated more aggressively at any given size.
- Small and asymptomatic primary: conservative, with follow-up
- Symptomatic or large: needle aspiration, then a chest drain if that fails
- Secondary: usually admission, with a low threshold for a drain
- Recurrent: pleurodesis or surgical pleurectomy
Advice afterwards: stop smoking, which markedly reduces recurrence; no flying until resolved and for a period after; and never dive again unless definitive surgical treatment has been carried out.